Improving the Quality of Postabortion Care Services in Togo Increased Uptake of Contraception

Stembile Mugore; Ntapi Tchiguiri K Kassouta; Boniface Sebikali; Laurel Lundstrom; Abdulmumin Saad

doi:10.9745/GHSP-D-16-00212

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Providers practice IUD insertion on pelvic models during postabortion care training.
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FIGURE 1.
Percentage of PAC Clients Who Received Counseling and Percentage of Those Counseled Who Accepted a Contraceptive Method, Pre‐Intervention (5 Months’ Duration) and Post‐Intervention (13 Months’ Duration), 2014–2015
Abbreviation: PAC, postabortion care.
Note: The pre‐intervention data include data from only 2 facilities that were offering contraceptive methods at the time, whereas the post‐intervention data include data from all 5 facilities that began offering postabortion family planning services after the Optimizing Performance and Quality training.
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FIGURE 2.
Percentage of Counseled PAC Clients Who Accepted a Contraceptive Method by Type of Method, Pre‐Intervention (5 Months’ Duration) and Post‐Intervention (13 Months’ Duration), 2014–2015
Abbreviations: IUD, intrauterine device; OCPs, oral contraceptive pills; PAC, postabortion care.

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TABLE Access to and Quality of PAC Services in Togo: Baseline Assessment Findings, Quality Improvement Solutions, and Results of Applying the Solutions

Baseline Findings	Quality Improvement Solutions	Results
Organization of services hindered access and quality: • Separation of treatment for abortion complications (in maternity ward), FP counseling (in postnatal ward), and provision of contraceptive methods (in FP unit located in the maternal and newborn health clinic), and no formal referral system from maternity ward to FP unit. • Clients had to purchase contraceptives from the facility pharmacy, open 8 a.m. to 5 p.m. on weekdays only, and return to the maternity or FP unit for contraceptive administration or instructions on how to use the method. • Clients had to wait for services if delivery room was full, which put clients treated for septic abortion at risk of infection.	• Facility-based quality improvement teams were oriented on elements of successful PAC during OPQ training and supported, during on-site supervision, to reorganize services to ensure privacy during treatment and counseling, improve infection prevention practices, and ensure availability of contraceptives at point of treatment. • Facility managers were sensitized to the importance of postabortion FP services, which mobilized their support for creating a separate space/room for PAC treatment and FP services to be used 24 hours per day, 7 days per week.	• All 5 clinics provide a full range of contraceptive options at point of treatment for abortion complications. • At 3 health facilities, services were reorganized to provide FP counseling and methods around the clock at point of treatment for abortion complications, either in a separate room for PAC or in the delivery room, which is also used for emergency obstetric care. • At 2 health facilities, due to lack of space, the FP providers who provide treatment and counseling also provide contraceptives in the units to which they are allocated
Very limited FP counseling was offered to postabortion clients, although a range of contraceptives were available at the facilities: • At 3 facilities, no PAC clients were counseled or offered contraceptive methods. • At 2 facilities, counseling was largely reserved for the few clients who had a self-induced abortion, and contraceptive choice was limited to pills.	• Providers were trained to improve PAC competencies, establishing counseling for all PAC clients on the full range of contraceptives by addressing provider bias; stigma, particularly toward young unmarried clients; need for FP services regardless of whether abortion was induced or spontaneous; rights-based care; and eligibility criteria for contraceptives following emergency treatment of abortion complications.	• Mix of contraceptive methods expanded to include injectables, implants, and IUDs. • Significant increases in counseling and contraceptive uptake among all PAC clients.
Few providers were trained to offer long-acting implants or IUDs: • Those trained had not had a refresher training for more than 5 years in either administration of long-acting methods or emergency treatment for abortion complications.	• Providers received competency-based trainings and follow-up support on MVA for treatment of abortion complications and provision of contraceptives, with a focus on updating contraceptive technology competencies to address barriers to contraceptive methods, counseling skills, and provision of IUDs and implants.	• Improved provider competencies for MVA, implants, and IUDs. • Significant increase in percentage of PAC clients choosing implants.
Four out of 5 health facilities did not have IUD kits readily available. • Instead, providers assembled kits from other instruments in the theater and maternity ward.	• The national quality improvement team was mobilized to address procurement and logistics and conduct regular supportive supervision at facilities to monitor and procure stocks.	• All facilities now have IUD kits.
Costs for services varied by location. • Treatment for abortion complications cost US$25–$30, including purchasing supplies; the range of costs of contraceptives were US$0.25–0.50 for 3 cycles of oral pills, US$0.25–$1.50 for injectables, and US$4–$6 for implants and IUDs. • High costs prohibited access to more expensive contraceptives.	• Discussions were held with facility managers and policy makers on cost of services. • At 4 facilities, a decision was made to offer free contraceptives to PAC clients by using contraceptive stocks from mobile units, which were already offered for free. (At 1 facility, clients still pay for contraceptives, which continues to impede access.) • The extent to which costs were a barrier to access and influenced method choice (e.g., clients opting for less expensive contraceptives) was documented in order to influence policy on free contraceptives for clients.	• Significant increase in uptake of contraceptive methods among PAC clients.
Health information systems were neither standardized nor effective: • PAC registers were not standardized. • Data quality was generally poor—with multiple data entry points where PAC clients received services, and clients who were referred to the FP unit for contraceptives or who returned for their 7-day check-ups were not tracked. • Data were not being used for decision making.	• PAC registers were standardized by adapting the register from the PAC Global Resource Center for use in Togo. • Providers were oriented to complete the registers during on-site supportive supervision. • Registers were reviewed for accuracy and consistency. • Monthly data were submitted to leadership—including facility managers and the Division of Family Health. • Continuous support for data collection and analysis was offered to providers, and progress was analyzed against the desired performance detailed in facility action plans.	• Facilities use a standardized PAC register that tracks PAC services, including family planning counseling and uptake of contraceptives by method. • There is a marked improvement in completeness of registers and quality of data. • Data are routinely analyzed and used to monitor progress toward set performance objectives and to update performance and quality improvement plans.
No links existed between facility-based providers and community health workers: • Facility-based providers were not involved in community efforts to create awareness of the dangers of unsafe abortion, importance of seeking services for bleeding during pregnancy, and merits of obtaining contraceptives during the postabortion period.	• Providers from all 5 facilities conduct talks, in communities, antenatal, postnatal, and child health clinics, focusing on the dangers of unsafe abortion and generating demand for FP services. • National quality improvement teams are charged with strengthening community–facility links.	• Links between communities and facilities are improved.

Abbreviations: FP, family planning; IUD, intrauterine device; MVA, manual vacuum aspiration; OPC, Optimizing Performance and Quality; PAC, postabortion care.